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HomeMy WebLinkAboutNCS000390_DOSA Form_20220927I ku RECEIVED QWLR-Stormwater Program NC Department of Environmental Quality •'�' Division of Energy, Mineral and Land Resources mn.•n.,..eaQuaulr Stormwater Permit Delegation of Signature Authority Form 0,rertlons are in red This form shall be used to delegate signature authority from the permit Owner (Permittee) to anotherparty. Only the Responsible Official defined below may submit permit applications and reports required by the permit (such as Data Monitoring Reports and Annual Reports) until this form is completed and submitted to the DEMLR Stormwater Program. Please note that delegating signature authority does not relleve the Permit Owner from the responsibility for permit compliance. a The permit Owner is the legal entity to whichfwhom a permit has been issued, and maybe an individual or an organization such as a company or government agency. Every Owner is required to have a Responsible Official who meets the legal signature authority requirements inalit) CFR 127.72. summarized below, • Fora corporation, the Responsible Official shall be a president, secretary. treasurer, orvice. president in charge of a principal business function. or another individual who performs similar functions for the corporation, or the manager of one or more manufacturing. production. or operating facilities who is authorized to make management decisions about the facility operation • For a partnership or sole proprietorship, fire Responsible Official shall be a general partner or the proprietor, respectively: or • For a municipality. State. Federal. or other public agency. the Responsible Official shall be either a principal executive ofcer!City/County Manager) or 2M;ing elected official fMayorl. a Even it delegated signatory authority has been delegated to another individual. the Responsible Official retains responsibility for compliance with permit conditions. Organization Name: Heritage Crystal Clean, LLC Responsible Official Neme: Anita Decina Responsible Official Title: Vice President. Operational, Safety 8 Environmental Excellence Email Address: anita.decina@crystal-dean.com IPhone:1847-783-5924 Mailing Address: 2000 Center Drive, Suite East C300 City: :Hoffman Estates State: 41- Zip: 60192 Stormwater Delegation of Signature Authority Form Page 1 M.: A. Persons to Receive Signatory Authority The signatures of the persons listed below indicates their acceptance of signatory authority. Delegated Party Name: lRebekah Schulenberg Delegated Party Title: Environmental Manager Permit Number: _ NC5000390 Email Address: Phone: MilThg Address: 000 Center Drive. Suite East C300 City:Hoif EstataIWV� I State: IIL _ ZiP: 60192 i Slgne�ure of Delegated Party Indicating ameplenee of Signatory AuNodty: —._. Date: Delegated Party Name: Greg Taylor _D_elegated Party Title: Plant Manger Permit Number. _ NCS000390 Email Address: greg.laylor@crystal-clean.com I Phone: I(704) 634-0006 Mailing Address: 2115 Speedrail Ct. City: Concord I State: NC I ZIP: 128025 Signature or Delegated Pany Indicating acceptance of Signatory AuNodty.CJ_ Delegated Party Name: Delegated Party Title: Permit Number:_ Email Address: I Phone: Mailing Address: City: _.— -- --- — ---- State: ZIP. ( -- Signature of Delegated Party indical'ng acceptance of Signatory Authority. Date: Delegated Perry Name: I Dele ated Party Title_: Perot Number: Email Address: I Phone: Mailing Address: City:' , Signature of Delegated Party indkaling accepumce of Signatory Authority Date: - ----- ----- — Slormwater Permit Delegation of Signatory Authority Form Page 2 B. Responsible Official Signature The Responsible Official, as identified in accordance with 40 CFR 122.22, is the appropriate individual with the authority to sign and submit reports for the organization. As the Responsible Official, I. Anita Decina _ (printed name). have the authority to enter into this Agreement for Heritage Crystal Clean, LLC (OwnedOrganization Name). I request that the DEMLR Stormwater Program include the persons listed in Part A of this form signatory authority for the above -named permit. acknowledge that I, and the persons listed in Part A of this form work atlfor my organization and have authority to act as a signatory for purposes of the NCDEQ's electronic document systems. By submitting this application, I, Anita Decina (printed name), have read, understand, and accept the terms and conditions of the stonnwaler permit(s) for which I am the Responsible Official. UK-, 1>w� Responsible Official Signature Vice President, Operational, Safety & Environmental Excellence Title Date Stonnwater Permit Delegation of Signatory Authority Form Page 3